mymontanasmiles.com - Patient Registration

PATIENT REGISTRATION
Patient's Full Name

First NameLast Name
Social Security #
Spouse Name

First NameLast Name
Social Security #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent's Name (If Minor)
Address
Parent's Employer
Work Address or Phone
Patient's Employer
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse's Employer
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Friend or Relative living in the Bozeman Area
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
In case of emergency, whom should we notify?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Who will pay this account?
Do you have Dental Insurance?
If yes, Insurance Company
Referred By
Policy #
MEDICAL HISTORY
Date of Birth

MonthDayYear
Date
Age
Date of last Medical Exam

MonthDayYear
Date
Name of Physician
Do you have, or have you had any of the following? Check all that apply
Do you have any other medical conditions?
Women:
Are you pregnant?
If yes, Due Date

MonthDayYear
Date
Are you taking any Birth Control Pills?
Are you Allergic to any of the following?
Penicillin
Other Antibiotics
If yes, what antibiotics?
Local Anesthetic
Other Drugs
If yes, what drugs?
Foods
if yes, what foods?
Are you taking any medications now?
if yes, what medications?
Permission is hereby granted to Dr. Blanchard to perform any necessary dental work for this patient.
Patient's Signature (Parent If Minor)
Date

MonthDayYear
Date
Should be Empty:

PATIENT REGISTRATION

MEDICAL HISTORY

Women: